Describe aural polyp with its causes and management.

Nature and Causes

• An aural polyp is a smooth, reddish, pedunculated mass of granulation or oedematous mucosa arising from the middle ear or mastoid and prolapsing through a perforation into the external canal.
• It is a sign of underlying disease, never a diagnosis in itself.
• Causes — and the list must be worked through, because the polyp is only what is visible:
• Cholesteatoma (atticoantral CSOM) — the most important.
• Chronic suppurative otitis media of the tubotympanic type, with polypoid mucosa prolapsing through a large central perforation
• A retained foreign body or a grommet acting as a nidus.
• Tuberculous otitis media, with pale exuberant granulations
• Malignancy — squamous carcinoma of the middle ear or canal, and in a child, rhabdomyosarcoma.
• Glomus tumour (paraganglioma), which is vascular, pulsatile and bleeds profusely — and is the reason blind avulsion can be disastrous
• An aberrant internal carotid artery or a high dehiscent jugular bulb.
• Fungal disease and inflammatory granulations in a mastoid cavity

Management

• The cardinal rule IS never TO avulse AN aural polyp blindly. This is the whole clinical point of the topic, and the reasons are:
• It may be attached to the ossicles — traction can dislocate the stapes and cause a dead ear with severe vertigo
• It may arise through a labyrinthine fistula, and avulsion opens the labyrinth
• It may be attached to the facial nerve where the canal is dehiscent, causing permanent palsy
• It may be a glomus tumour or an aberrant carotid, causing catastrophic haemorrhage
• It may extend intracranially through an eroded tegmen, so that traction tears dura or brain — an encephalocele may present as a "polyp"
• Correct management:
• Image first where there is any doubt, and always before removing a polyp that is pulsatile, bleeds readily, or is associated with neurological signs
• Take a biopsy of the surface under vision if malignancy or tuberculosis is suspected — but a biopsy is not an avulsion, and vascular lesions should not be biopsied in the clinic
• Remove it under microscopic vision, using cup forceps or a snare, dividing the pedicle rather than pulling, and ideally as part of the definitive operation
• Send all tissue for histopathology, without exception — this is how tuberculosis, rhabdomyosarcoma and carcinoma are found